HIV testing in Africa: will VCT for all do more than ABC approach?

Two contrasting viewpoints on voluntary testing and counselling for HIV in developing countries are put forward this week in The Lancet. Whilst Dr Kevin De Cock of the US Centers for Disease Control in Kenya argues that universal voluntary counselling and HIV testing (VCT) is the only way to get a grip on the epidemic in sub-Saharan Africa, Dr Jeffrey Stringer of the Centre for Infectious Disease Research in Zambia suggests that in the short term, VCT cannot be implemented on the scale needed to meet one of the most ambitious United Nations goals – the reduction of mother to child HIV transmission by 20% by 2005 and by 50% by 2010. Instead, he argues, nevirapine treatment should be universally deployed for all women giving birth in high prevalence areas.

Kevin de Cock first put forward the view that Africa needed to move swiftly towards universal voluntary counselling and testing at the Eighth Conference on Retroviruses and Opportunistic Infections in 2001 ( click here for a report on that speech, arguing that: “The human rights/AIDS exceptionalism approach is promoting an African holocaust”.

This week in The Lancet he argues that the ABC (abstinence, be faithful, use a condom) approach to HIV prevention ignores the possibility that partners in a relationship might have different HIV statuses. He points to the example of rural Uganda, where a study of HIV transmission within marriage found that the age-specific incidence of HIV infection was 106 times higher in women married to HIV-positive men when compared to women married to men who were HIV-negative at the outset of the study.

One argument against expansion of voluntary counselling and testing has been that no incentive exists to test for HIV if teratment is not avaialble. However, de Cock points out that the vast majority of people eligible for treatment in sub-Sahran Africa will be identified as a result of presentation with symptoms of HIV disease or tuberculosis, and testing should be universal for all patients admitted to hospital or terated for TB. Asymptomatic individuals identified through testing will only be eligible for treatment if they are pregnant women.

Routine HIV testing should be integrated into health services to prevent disease progression wherever possible (by use of prophylaxes) and to prevent onward transmission of HIV. The authors recommend: “A public health goal should be for every African adult and adolescent to know his or her HIV status, and to be retested in case of potential exposure.”

The only African country to have embraced such a policy so far is Botswana, where the government announced that testing would be routinely offered in all public medical facilities, including antenatal clinics, from January 2004. Patients will need to opt out of testing if they do not want to know their HIV status, and private medical facilities are being encouraged to adopt the same policy.

However, Dr Jeff Stringer reports on experience from Zambia, where it took 19 months to roll out a mother to child transmission prevention programme, chiefly because of the time involved in training midwives in voluntary counselling. “During this period 7,000 HIV-positive women gave birth in clinics that did not have VCT services,” he writes; “Thus more than 7,000 infants were exposed to HIV-1 but received no prophylaxis, despite the district pharmacy being fully stocked with nevirapine.”

“We estimated that our decision to require testing services to be in place before implementation of nevirapine resulted in the infection with HIV-1 of at least 300 otherwise healthy infants.”

Instead, nevirapine should be given to all women giving birth in the absence of voluntary counselling and testing. He argues that there are many precedents for population-wide prophylaxis in high prevalence settings, including malaria, schistosomiasis, trachoma, filiariasis and intestinal helminths.

But he acknowledges that such a practice could undermine the expansion of VCT and prevention goals in the short-term if health care workers and policy makers become complacent, believing that children are protected from HIV by blanket nevirapien coverage.